Effect of Salmeterol-Fluticasone Combination and Tiotropium on Clinical and Physiological Improvement of Bronchial Anthracofibrosis: a Double Blind Randomized, Cross Over, Placebo Controlled, Clinical Trial.

Background: Bronchial anthracosis is the black discoloration of bronchial mucosa that exhibits similar manifestations to Chronic Obstructive Pulmonary Disease ( COPD). The etiology of this obstructive lung disease has not been elucidated and standard therapy for this disease has not been introduced in the literature. The objective of this study is to determine the efficacy of the salmeterol-fluticasone inhaler and tiotropium as two safe treatments of obstructive lung disease for the treatment of symptomatic subjects of anthracofibrosis of the lung. Materials and Methods: Twenty anthracofibrosis subjects who suffered from dyspnea were enrolled in this three-phase, cross over, placebo-controlled clinical trial. The primary outcome variable was quality of life (evaluated with the CAT questionnaire). Clinical findings and spirometry were the secondary outcome variables. Both of these drugs were delivered by an inhaler and were made identically by the reference manufacturer. Salmeterol-fluticasone was prescribed with a spacer and tiotropium by its special device, and the method of utilization was taught to the patients. Results: Twenty anthracofibrosis subjects were enrolled in this three-phase, five-month course of treatment with either salmeterol-fluticasone or tiotropium inhalers. The response to therapy was not good; neither for salmeterol-fluticasone nor for tiotropium in the short course of the treatment. However, the overall results of 5 months of therapy with both of the drugs have shown improvement in 57% of the subjects. The most prominent results were found in the CAT score [25.1±5.54 before the trial, which decreased to 19.2±5.14 (Z score=2.7, P=0.007)] and clinical findings especially sputum, chest pain, and wheezing (81, 94 and 92% before the trial and 50, 56, 54% after the trial, respectively). Neither clinical findings nor spirometry was able to predict a good response to salmeterol-fluticasone or tiotropium. Conclusion: The combination of salmeterol-fluticasone and tiotropium inhaler was able to improve the clinical findings of symptomatic anthracofibrosis patients.


INTRODUCTION
Bronchial anthracosis is the black discoloration of bronchial mucosa and is an old disease that is being increasingly reported in Asia, especially in rural areas (1,2).
Sometimes this is an accidental finding during bronchoscopy, but in a more severe form called  Randomization and random allocation: Placebos for the salmeterol-fluticasone inhaler and tiotropium were obtained from the producer of the drugs (Cipla Co., Goa, India) and were completely similar in appearance to the originals. The drugs were coded before the study and then a pharmacist, blinded to the situation of the subjects, distributed the drugs to them. The physician or any of the patients did not know the type of drugs they were started on. The drugs were randomly distributed to the two groups using a computational random number generator (SPSS software). Anthracofibrosis subjects were divided into two groups randomly based on study protocol ( Figure 1).

First phase
For the first group (10 subjects), the salmeterolfluticasone combination was prescribed and a placebo in place of tiotropium for one month. The second group (10 subjects) was prescribed tiotropium and a placebo for the salmeterol-fluticasone combination. After one month, subjects were reassessed by three tools to measure outcome variables as mentioned above, and then all of the subjects were administered a placebo for a drug washout.

Second phase
Next, the group's subjects were crossed over to the other group and administered the other drug and placebo for one month. Afterward, they were evaluated again for outcome variables and were administered the placebo for drug washout.

Third phase
The subjects in both groups were combined (20 subjects) and received salmeterol-fluticasone and tiotropium together for one month. At the end of this phase outcome variables were evaluated for the fourth time and the subjects were questioned regarding t he side effects of the drugs. At the end of this phase, the study was completed.

Statistical analysis
According to the frequency of anthracofibrosis in our

RESULTS
Twenty anthracofibrosis subjects, whose diagnosis were proven by bronchoscopy and suffered from respiratory symptoms, were enrolled in this study.
Bronchoscopic findings showed that anthracofibrosis was localized in some lobar bronchi in five (25%) subjects and it was diffuse in 15 (75%) subjects. One subject showed associated lung fibrosis in addition to anthracofibrosis.
These 20 subjects completed one-month courses of salmeterol-fluticasone combination/placebo and tiotropium/placebo therapy sequentially. From these two groups, two subjects improved and did not continue with the third phase of the salmeterol-fluticasone combination/tiotropium therapy.

Demographic data
Mean Computed tomography was performed in eleven subjects. Lymph node high attenuation (calcified like lesion) was observed in 5/11 (45%) and a mass with or without high attenuation in 8/10 (80%). Table 1 shows the clinical findings of the anthracofibrosis subjects who received salmeterolfluticasone and a placebo of tiotropium. Among these five major clinical findings, dyspnea was the most frequent and wheezing in the physical examination showed the best improvement, although none of the changes after the treatment were statistically significant.   Evaluation of the CAT questionnaire showed improvement in some parameters especially step tolerance (P=0.02), disability during work, and sleep quality ( Table 2).

Effects of the salmeterol-fluticasone inhaler on anthracofibrosis
Total CAT score as the cumulative result of the CAT questionnaire showed severe disability and low quality of life, which improved non-significantly with treatment (Table 2).
Spirometry parameters showed moderate mixed restrictive and obstructive type impairment (Table 3).
Treatment with salmeterol-fluticasone was able to improve the small airway obstruction as shown by significant improvement of FEF25-75 and FEF25-75/FVC (Table 3).
Restrictive pattern was the predominant pattern of the spirometry before and after the trial (Figure 3).    Although some improvement could be found in some parameters such as cough, sputum, and sleep quality, the statistical analysis did not show significant differences.

Effects of tiotropium on anthracofibrosis
Sputum type was mostly whitish in appearance, but after treatment with tiotropium, it changed to no sputum

Effects of the combination of tiotropium and salmeterolfluticasone inhaler on anthracofibrosis
Improvement in some clinical findings were evident by using the tiotropium inhaler and the salmeterol-fluticasone in our anthracofibrosis subjects, especially in those with sputum and wheezing (41 and 31% improvement, respectively) ( Table 1), but the statistical analysis did not show significant changes. Figure 2 shows the different types of sputum in these subjects and it shows nonsignificant decrement of whitish and mucoid sputum toward subjects without sputum (X 2 =12, P =0.21). On the other hand, analysis of the CAT questionnaire results showed significant improvement in dyspnea and outside activity (P-value 0.01 and 0.05, respectively).
Other parameters of the CAT score, including total score, showed some improvement, although not significant ( Table 2). Spirometry analysis also did not show significant changes before and after treatment with the tiotropium and salmeterol-fluticasone inhaler (  (Figure 3).  (Table 1).
After the complete course of the study, sputum disappeared in five subjects (31%) and the color of sputum changed significantly to a whitish color in six (75%) subjects and in two (25%) subjects it turned to yellow ( Figure 2) (X 2 =20, P=0.01).

Assessment of quality of life by the CAT
questionnaire also showed improvement of quality of life.
The changes during the trial were not significant for cough, sleep quality, and weakness, but the remaining parameters were improved significantly ( Table 2).

Predicting factors for good response
Demographic data, clinical findings, CAT score, and spirometry results were compared between the two groups of responders and non-responders to determine the best predicting factors for good response to treatment. Tables 4 and 5 show the most suitable demographic, occupational, clinical, radiological, and physiological (spirometry) findings that could help determine a predictive factor for good response to long term bronchodilator with or without inhaled corticosteroid.
Comparison of these risk factors did not show any significance for any of them, but the odds ratio and 95% confidence interval showed a role for baking, cough, wheezing, and chest pain for predicting a good response.
Furthermore, the type of sputum in improved subjects was equally whitish and yellowish in color in both groups; therefore, it was not a predicting factor for improvement.  (7).
In Western countries, as biomass use has decreased considerably, occupational exposure to coal has remained the most important risk of acquiring native anthracosis (8).
However, as the origin of an anthracotic nodule in the vesicles of bronchial macrophage is undefined, none of these studies were able to introduce an effective treatment targeting the pathophysiology of the disease. Most comprehensive reviews recommend avoiding exposure to organic and in-organic dusts (9), but this strategy will not relieve the clinical symptoms and illness of anthracofibrosis patients.
Treatment of associated tuberculosis usually makes a considerable clinical and radiological improvement (10,11).
Decisions about starting anti-tuberculosis therapy are quiet easy, as the diagnosis of anthracofibrosis requires bronchoscopy and during bronchoscopy enough samples for the diagnosis of tuberculosis can be accumulated (12).
We should assume that all subjects of anthracofibrosis may not be associated with tuberculosis (13) Since there is no method presently to remove an anthracotic nodule from the bronchial mucosa, authors of this research and many other physicians in our region prescribe the long acting bronchodilator for the treatment of anthracofibrosis. The rational of selecting this treatment is adapted from COPD. We should remember the influence of biomass in the formation of both COPD and anthracofibrosis. Therefore, choosing long acting bronchodilators might be prudent in anthracofibrosis such as COPD. In this study, long acting beta2-agonist (salmeterol) and long acting anti-muscarinic agent (tiotropium) were chosen for the treatment and were compared with each other. Salmeterol was combined with inhaled corticosteroids to better cover asthma-like bronchial disease. All of these drugs are safe and are available in low-income countries. The results of this research have shown that beneficial effects of these drugs cannot be shown in the short course of therapy, but longterm usage is helpful. Due to the low mortality and morbidity rate of this disease (1,5) in comparison to COPD, we recommend using these drugs for the long term; usually more than three months, especially during the winter season and to start with one drug and add another one if an appropriate response is not seen. We also recommend another research to compare the effect of LABA alone with the combination of LABA-ICS. In conclusion, the long acting bronchodilator including long acting beta2-agonist and long acting muscarinic antagonist with or without inhaled corticosteroids are safe and effective drugs for the treatment of symptomatic bronchial anthracofibrosis.

Conflict of interest
The authors of this article did not receive any grant from any drug company and the provider of placebo delivered the placebo`s free of charge and did not get involved in any part of design and analysis of this study.